HomeMy WebLinkAbout022-638-22-1201-SAN-2021-367 ,
"'"""�; PRIVATE ONSITE WASTE TREATMENT counry
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�'=�"�^'=' INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �1 .36'7
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)J �
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: m 2- 1 P � �p'r ri�T �i �G�S;g'� Parcel Tax No:
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TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark � pp,c r
Dosing (�r�, � (� ��'g�'
Aeration Bldg. Sewer q �,��'
Holding 5 K�/ ,� -7�--b St l Ht Inlet �/,q��
TANK SETBACK INFORMATI N St I Ht Outlet ��,� '
TANK TO P/L WELL BLDG VENTTO ROAD Dt inlet
AIR INTAKE
Septic NA Dt Bottom �j ,�'3�
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding � ��� �a� fi2�� ��S' Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative
Surface
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Weil
DISPERSAL CELL INFORMATION
DIMENSIONS W � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav ° Conv ❑ Aggregate
P I L Bldg Well ❑ IGP ❑ Chamber
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO ❑ Mound o Other
- -- —--- _____ —---
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes
Length Dia �Length Dia _ Spac � _ Spacing ❑Yes ❑No
SOIL COVER
- -- -_____ _ -- --
Depth Over Depth Over ; Depth of Seeded I Sodded Mulched
Cell Center Cell Edges I_Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies,persons present,etc.)
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Plan revision required?❑Yes❑ No �d3 I,� a I = � i 6� �
Use other side for additionai information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:____�__�6�_
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